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. 2025 Nov 27:qcaf145.
doi: 10.1093/ehjqcco/qcaf145. Online ahead of print.

Clinical Characteristics, Management and Outcomes of Enterococcal Infective Endocarditis: An Ancillary Study from the ESC-EORP EURO-ENDO Registry

Mary Philip  1 , Robinson Gravier Dumonceau  2 , Rodolfo Citro  3 , Bernard Cosyns  4 , Erwan Donal  5 , Paola Anna Erba  6 , Frédérique Gouriet  7 , Bernard Iung  8 , William K F Kong  9 , Patrizio Lancellotti  10 , Aldo Maggioni  11 , Julien Mancini  2 , Bogdan A Popescu  12 , Bernard Prendergast  13 , Antonia Sambola  14 , Shantanu P Sengupta  15 , Ana Timoteo  16 , Christophe Tribouilloy  17 , Joost Van Melle  18 , Roch Giorgi  2 , Gilbert Habib  1 ; EURO-ENDO Investigators
Collaborators, Affiliations

Clinical Characteristics, Management and Outcomes of Enterococcal Infective Endocarditis: An Ancillary Study from the ESC-EORP EURO-ENDO Registry

Mary Philip et al. Eur Heart J Qual Care Clin Outcomes. .

Abstract

Background: Enterococcal infective endocarditis (EIE) represents a growing proportion of infective endocarditis (IE) cases, particularly among elderly and comorbid patients. EIE poses diagnostic and therapeutic challenges, notably regarding optimal antimicrobial therapy and surgical decision-making. We aimed to compare the clinical characteristics, management, and outcomes of EIE versus non-enterococcal IE (NEIE) in the ESC-EORP EURO-ENDO registry.

Methods: This ancillary analysis of the prospective EURO-ENDO registry included adult patients with definite or possible IE enrolled between January 2016 and March 2018. Patients with monomicrobial EIE were compared with those with NEIE. Clinical, microbiological, imaging, and therapeutic data were analyzed. Multivariable logistic regression including EuroSCORE II and valve status identified independent predictors of in-hospital mortality.

Results: Among 3 083 patients, 365 (12 %) had monomicrobial EIE. Compared with NEIE, EIE patients were older (mean 68 vs 58 years), had more comorbidities, and more frequent prosthetic valve involvement (41 % vs 26 %). Aortic valve localization and colonic uptake on PET/CT were also more common. In-hospital mortality was similar (16 % vs 17 %). After adjustment for EuroSCORE II and valve status, EIE was not independently associated with higher in-hospital mortality (adjusted OR 0.67 [95 % CI 0.42-1.04]; p = 0.083). Among 195 EIE patients with one-year follow-up, recurrence occurred in 6 %. Healthcare-associated acquisition, prosthetic valve infection, and recurrence were associated with worse outcomes and lower surgical rates.

Conclusions: EIE affects older, high-risk patients. After adjustment for operative risk, mortality was comparable to other etiologies, highlighting the need for tailored diagnostic and therapeutic strategies.

Keywords: Dual beta-lactam therapy; Enterococcal endocarditis; Healthcare-associated infection; Prosthetic valve infection; Recurrence; Surgical management.

Plain language summary

Infective endocarditis (IE) is a serious infection of the heart valves. One specific form, called enterococcal endocarditis, is becoming more common, especially in older patients with other health problems and in those who have had recent contact with hospitals or medical procedures. We analyzed data from over 3,000 patients in the large European EURO-ENDO registry to better understand how enterococcal endocarditis differs from other forms of IE. We found that patients with enterococcal IE were older, sicker, and more likely to have artificial heart valves, such as those implanted during open-heart surgery or through transcatheter techniques (TAVI). Although their symptoms were sometimes less severe at the beginning, these patients had fewer surgeries and more frequent recurrences of the infection. We also found that early surgery and better imaging techniques, such as PET scans, were linked to better outcomes. This study highlights the need for personalized treatment strategies in this vulnerable population, including better diagnostic tools, more consistent use of surgery when needed, and thorough investigation for hidden sources of infection, such as colon cancer. Improving the care of patients with enterococcal endocarditis could help prevent relapses and save lives. KEY LEARNING POINTS Enterococcal infective endocarditis (EIE) primarily affects older, comorbid patients and is frequently associated with prosthetic valves and healthcare-associated acquisition.Despite high rates of surgical indication, surgery is often underused in EIE, particularly in prosthetic valve infections, and this is associated with worse outcomes.Advanced imaging techniques (notably PET/CT) and systematic colorectal evaluation are underutilized but may improve diagnosis and guide treatment in EIE.Recurrence within one year, although relatively infrequent, highlights the complexity of antimicrobial management and the importance of optimized source control.Tailored management strategies, including multidisciplinary heart team evaluation and individualized antibiotic regimens, are essential to improve outcomes in this high-risk population.

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